Exploring Facets of Nurse Practitioner-Owned Practices

Background

Nurse Practitioners (NPs) are a vital part of the healthcare workforce and play a critical role in meeting the needs for healthcare services in the United States (US). To become an NP, a registered nurse is required to complete a master's or doctoral-level program that provides advanced clinical training and education beyond an undergraduate nursing degree, along with fulfilling local licensure and national certification requirements to practice (Alexander & Schnell, 2019). The advanced nurse practitioner role was formally defined by the International Council of Nurses (ICN) as a profession that demands specialist knowledge, clinical skills, and complex decision-making for individuals across the lifespan in diverse care settings (Htay & Whitehead, 2021). The NP role is the fastest growing healthcare profession in the US (Hovsepian et al., 2023).

Evidence has shown that care provided by an NP is safe and of high quality (Stanik-Hutt et al., 2013). Additionally, evidence supports a comparable level of care and outcomes for patients cared for by NPs when compared to physicians (Htay & Whitehead, 2021). The American Association of Nurse Practitioners (2022) projects NPs will comprise nearly a third of all primary care providers nationwide by 2025 (Barns et al., 2018). NPs in primary care practices led by NPs with full practice authority present a potential solution for the growing healthcare demands and the primary care physician shortage. However, not all NPs have authority to practice to the full extent of their education and training. State-dependent scope of practice regulations make it challenging for NPs to practice without physician oversight, which imposes limitations on the services an NP can provide (Hovsepian et al., 2023). Moreover, The American Medical Association (AMA), a national professional organization representing physicians and medical students in the US, has criticized the expansion of state-level scope of practice legislation for NPs (Alexander & Schnell, 2019). This state-regulated limitation is a commonly cited barrier to NP-led practice.

The US Department of Health and Human Services and the Health Resources and Services Administration (HRSA) identified an estimated 6,464 healthcare provider shortage areas across the US in 2022, with 165 million people living in workforce shortage areas (Bureau of Health Workforce, 2023). AUTHOR: This citation is not in references The American Association of Medical Colleges (AAMC, 2026) projects a physician shortage of 122,000 by the end of 2023. Additionally, the rising demand for chronic disease management has strained the healthcare system and makes the shortage of primary care physicians especially difficult. Currently, 325,000 licensed NPs serve approximately 1 billion patients annually in all 50 states (AANP, 2023). AUTHOR: This citation is not in references Of these states, only 27 states and the District of Columbia allow autonomous NP practice without physician oversight (AANP, 2023). AUTHOR: This citation is not in references Despite barriers to full practice authority in some areas, evidence shows that NPs have significantly reduced healthcare staff workload, lowered costs, boosted patient satisfaction, and improved the efficiency and accessibility of healthcare services. Removing practice barriers for all NPs could greatly increase access to care.

Some NPs with full practice authority have responded to the need for increased access to primary care health services by developing both independent and collaborative care practices. Independent practice models involve a single NP provider who delivers healthcare services to patients and bears all practice costs. NP-led collective practice models consist of a group of NPs who may work together or independently but share practice expenses and/or an electronic medical records system. As NP-led practice continues to grow, research is needed to address the gaps in literature about the experiences of NPs in private practice (Waite, 2019).

Purpose

The purpose of this project was to better understand NPs' experiences in developing their own private practice. There were three main objectives of the project:

1. Determine NPs’ decision to start their own private practice.
2. Explore the limitations and benefits of private practice.
3. Examine independent vs collective practice models.

Methods

An initial review of the literature was conducted to identify current findings related to NPs' experiences in private practice. Although findings were limited, this review helped guide the development of survey content and questions aimed at better understanding NPs in private practice. An overview of the survey questions is provided in Table 1. The survey included 26 questions, which were a mix of select-all-that-apply, open-ended, and Likert scale questions. It was created using web-based survey software and distributed for data collection. Since the survey was anonymous and voluntary, institutional review board approval was not required. Purposive sampling was employed, and the survey was emailed to locally recognized independent NP practices and to practices identified through local NP chapters. Additionally, the survey was shared on several social media groups focused on NPs in private independent practice. Quantitative data were analyzed using statistical software, primarily with descriptive statistics. Data analysis was conducted by one author and reviewed by coauthors. For qualitative data, open-ended responses were reviewed by the authors and categorized based on identified themes.

Table 1: Content & Survey Questions

Results

Demographics
A total of 17 respondents completed the survey. Most respondents were female (94%), aged between 33 and 72 years, with an average age of 49 years. Experience as an NP ranged from 2 to 30 years, with a mean of 11 years, and an average of 7 years of experience before starting an independent practice. Educational attainment included 59% with a master's NP specialty and 41% with a Doctorate NP specialty. The majority of participants reported practicing in a full practice location (65%), followed by 12% in a restricted practice state, 5% in a reduced practice state, and 18% with multistate licensure. Demographics of participants are shown in Table 2. An overview of all survey results by content area is provided in the Supplement.

Table 2: Demographics

Practice Description
Participants were asked to discuss their current independent practice services and specialties. Nearly all practices offered both in-person and telehealth visits, with 94% providing both options. Specifically, 88% offered in-person services, while 12% offered only telehealth services. The most common specialty was primary care at 35%, followed by combined primary care and mental health at 24%, as well as other specialty services also at 24%. Additionally, 17% reported providing psychiatric mental health services exclusively.

Decision making
Regarding decision-making about pursuing an independent private practice, participants reported the lack of flexibility in their schedule (82%) and feeling undervalued in previous roles (76%) as the main factors influencing their choice. They also cited poor compensation (71%) and large patient caseloads (71%) as significant concerns. Limitations to practice were the least reported factor, at 47%. When asked about other factors that might have contributed to choosing to start an independent practice, three themes emerged: challenges related to the healthcare system, personal goals or needs, and employer-specific challenges.

Barriers
When asked to identify the biggest challenges in starting an independent practice, participants reported building a patient panel (53%), followed by marketing (47%) and credentialing/billing (47%). Time management was cited less frequently (29%). Open-ended questions revealed three additional themes: funding, lack of administrative support, and identifying a population of focus for the practice.

Benefits & Supports
Participants were asked about the benefits of having an independent practice, and the vast majority agreed that advantages included control over their schedule (94%), better work-life balance (88%), improved compensation (82%), and control over the patient population (82%). The open-ended question about other benefits revealed themes such as spending more time with patients, providing higher quality care, and having independence in decision-making. When asked about additional support practice owners would like to have, they identified legal, accounting, administrative support, and more peer support.

Practice Models
Respondents were asked about their practice model, and 7 out of 17 reported practicing in a collective independent group practice, specifically a group of providers who work independently of each other but may share costs, provide support, or share an electronic medical records system. All 7 respondents said that benefits of this model included support and guidance during startup, clinical consultation among providers, and the ability to have coverage for time off. Seventy-one percent believed that shared costs in a collective practice model were also advantageous. Other qualitative findings from the review of open-ended questions showed that those practicing in a collective practice model also found benefits in shared responsibility, collaboration, referrals, as well as business support and inspiration.

Billing & Credentialing
Participants were asked about the use of credentialing and billing services, and 53% reported using this service, while 47% handled credentialing and billing themselves. When asked to rate the difficulty of the billing and credentialing process, 41% said it was somewhat difficult, 35% were neutral, and 24% reported it as extremely difficult.

Marketing
Respondents were also asked about challenges with marketing to build a patient panel. 35% reported this as somewhat difficult, 29% were neutral, 24% found it somewhat easy, and 12% said it was extremely difficult.

Satisfaction
The final part of the survey asked about satisfaction details. All respondents indicated some level of overall satisfaction, with 71% very satisfied, 23% somewhat satisfied, and 6% mostly satisfied. When asked if practice owners felt their practice is thriving, 70% agreed, 12% said their practice is progressing, and 18% did not believe their practice is thriving.

Supplementals

Discussion

NPs reported dissatisfaction in traditional practice settings. They indicated that working in a collaborative clinic environment that was supportive and provided coverage for time off was a benefit of independent practice. Similar to these findings, Li et al. (2023) discovered that NPs felt most dissatisfied when being supervised by a physician, not billing under their own NPI number, and not having their own patient panel. Additionally, NPs were unhappy working in an unsupportive environment. The ability to independently manage clinic schedules, spend more time with patients, and deliver high-quality care were primary motivators for NP independent practice. Evidence supports positive links between time spent with a clinician and patient satisfaction and outcomes. Patient compliance with treatment plans improves when scheduling allows enough time for clinicians to address individual patient needs. (Prasad et al., 2020).

Nurse practitioners (NPs) reported that their motivation to open their own practice was driven by a desire to find fulfillment and meaning in their roles. Waite (2019) found similar results, identifying questioning, self-directing, transforming, and achieving fulfillment as common themes among NPs who provide care in private practice. They reported feeling undervalued, overwhelmed with too many patients, underpaid, limited in their practice scope, and lacking flexibility in traditional roles. NPs who choose to own practices want to change how care is delivered and do so in a way that enhances personal satisfaction, allows for individualized care, and improves patient outcomes. Interestingly, Li et al. (2023) reported that an annual salary increase of $15 to $ 22,000 would be needed for an NP experiencing job dissatisfaction to continue in a traditional healthcare role. Such salary increases are generally not feasible within traditional healthcare models.

NP managed practices offer opportunities to prevent clinician burnout while addressing the critical need for better access to primary care. Prasad et al. (2020) described clinician burnout as being linked to schedules that do not allow enough time to meet patient needs. Private practice models that support well-being by providing patients with appropriate appointment lengths and access to quality care coordination for complex chronic illnesses are necessary. Current primary care practice models are not sustainable and fail to support the need for improving patient access to care.

Limitations

There were several limitations to this project. First, the sample was limited because there is no universal NP-owned practice database, and all practices could not be directly contacted, so the survey was designed as voluntary. Second, this project focused on understanding insurance-based practice models but did not include questions about cash practices or concierge medicine models. Third, while it was possible to identify state practice environments by location, additional questions could have been added to better understand practice challenges in restricted or reduced practice states. Future research might include a larger nationwide survey to gain a better understanding of experiences across different state practice environments and various care delivery models.

Implications

The survey findings provide insight and awareness into the increasing number of NPs choosing to become practice owners. They emphasize the need for full autonomous practice to improve access to care and boost NP role satisfaction. With the rising demand for primary care services, especially in rural areas, and a growing NP workforce, expansion of NP-owned practices is likely. Additionally, greater support for full practice authority for NPs and the adoption of multi-state advanced practice nursing licensure will continue to reduce barriers to NP-owned practices.

The development of innovative practice models will be necessary to meet the healthcare needs of patients in the US. Collective clinic models that support peer mentoring and share in business management best practices may be a beneficial approach for clinicians in independent practice. Furthermore, research is needed to explore NP-led collective clinical models and the extent to which they support NP role satisfaction. Studies investigating practice barriers, credentialing and billing services, and marketing would be valuable to further contribute to the growing body of literature on NP-owned practices.

Conclusion

Nurse practitioner–owned practices are an important and growing model of healthcare delivery that can help address workforce shortages while boosting provider satisfaction and patient access to care. Findings from this survey indicate that nurse practitioners who pursue independent practice are mainly motivated by a desire for professional autonomy, better work–life balance, and the ability to provide higher quality, patient-centered care. Despite challenges related to credentialing, marketing, funding, and administrative support, participants reported high satisfaction levels and considered their practices successful. These results emphasize the potential of NP-led practices to contribute significantly to healthcare system sustainability, especially given the increasing demands in primary care. Continued policy support for full practice authority, more research on NP practice models, and greater access to business and administrative resources will be crucial for the ongoing growth and success of nurse practitioner–owned practices.

Authors

Ashley Fenton, DNP, PMHNP-BC, FNP-C, LCSW-C
Email: afenton2@jhu.edu
ORCID ID:

Ashley Fenton, DNP, PMHNP-BC, FNP-C, LCSW-C, is an Assistant Professor at Johns Hopkins University School of Nursing, Baltimore, MD, and an APRN at The Collective NP Clinic in Gambrills, MD.

Leigh Montejo, DNP, FNP-BC
Email: lmontej1@jh.edu
ORCID ID:

Leigh Montejo, DNP, FNP-BC, is an Assistant Professor at Johns Hopkins University School of Nursing, Baltimore, MD.

Katherine G. Humphrey, DNP, CRNP, FNP-BC
Email: khumphr8@jhu.edu
ORCID ID:

Katherine G. Humphrey, DNP, CRNP, FNP-BC, is a faculty member at Johns Hopkins University School of Nursing, Baltimore, MD, and an APRN at the Collective NP Clinic, Gambrills, MD.

Colleen King Goode, DNP, MA, CRNP, FNP-BC, CNE
Email: cking65@jhu.edu
ORCID ID:

Colleen King Goode, DNP, MA, CRNP, FNP-BC, CNE, is an Assistant Professor at Johns Hopkins University School of Nursing, Baltimore, MD, and an APRN at The Collective NP Clinic, Gambrills, MD.

Lourdes Celius, DNP, CRNP, FNP-C
Email: lcelius1@jhmi.edu
ORCID ID:

Lourdes Celius, DNP, CRNP, FNP-C, is Clinical Faculty at Johns Hopkins University School of Nursing, Baltimore, MD, and an APRN at The Collective NP Clinic, Gambrills, MD.